Bordetella holmesii Bacteremia in Asplenic Children Report of Four

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Bordetella holmesii Bacteremia in Asplenic Children Report of Four

     JOURNAL OF CLINICAL MICROBIOLOGY, Oct. 2010, p. 37623764 Vol. 48, No. 10 0095-1137/10/$12.00 doi:10.1128/JCM.00595-10 Copyright ? 2010, American Society for Microbiology. All Rights Reserved.

Bordetella holmesii Bacteremia in Asplenic Children: Report of Four

    Cases Initially Misidentied as Acinetobacter lwof;i

    11,2334Markos Ioannis Panagopoulos,Maude Saint Jean,Delphine Brun,Nicole Guiso,Sadjia Bekal, 11Philippe Ovetchkine,and Bruce Tapiero*

    1Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada; 2Department of Microbiology and Immunology, CHU Sainte-Justine, University of Montreal, Montreal, Canada; 3Institut Pasteur, French National Reference Center for Pertussis and other Bordetelloses, Paris, France; and 4Quebec Laboratory of Public Health, Sainte-Anne-de Bellevue, Quebec, Canada

    Received 21 March 2010/Returned for modication 5 May 2010/Accepted 16 July 2010

    Bordetella holmesii is a fastidious Gram-negative rod that was initially identied in 1995. It causes bacter-

    emia, predominantly among patients with anatomical or functional asplenia. We report four cases of B.

    holmesii bacteremia in asplenic children occurring within the last 4 years. In all cases, B. holmesii was misidentied by an automated system as Acinetobacter lwof;i.

     Four male adolescent patients, aged between 13 and 17 tion condence level) for all isolates. Some basic characteris- tics did not match this result. A. lwof;i usually grows well on years, presented with mild febrile illness but no other clinically MacConkey agar, has a positive catalase activity, and does not signicant complaints within a period of 3.5 years. Three were produce any pigment. All isolates were subsequently identied suffering from sickle cell disease; two of them had undergone splenectomy. In the fourth patient, elective splenectomy was as Bordetella holmesii by 16S rRNA gene sequence analysis performed at Quebecs Laboratory of Public Health, as previ- performed for an autoimmune hemolytic anemia. No epide- ously described (2). miological link was found between the four patients. At the emergency department, they appeared well and had MICs determined by Etest on Mueller-Hinton agar were no remarkable ndings on physical examination or initial lab- 0.25 g/ml for piperacillin, ticarcillin-clavulanate, ceftazi- oratory workup. Blood cultures all grew Gram-negative bacilli. dime, meropenem, ciprooxacin, trimethoprim-sulfamethox- Two of the patients received intravenous (i.v.) ceftriaxone for azole, and polymixin E; MICs for gentamicin and tobramycin 2 and 7 days, respectively. The remaining patients were treated were 2 g/ml for one isolate and 0.25 g/ml for the remain- with i.v. ceftriaxone followed by oral ciprooxacin for a total of ing three. Although all patients were treated with ceftriaxone, susceptibility testing for ceftriaxone was not performed. 10 days.

    The clinical outcome was uniformly favorable. Clinical and The genus Bordetella belongs to the family of Alcaligenaceae

    laboratory ndings are summarized in Table 1. and currently comprises eight species, including B. holmesii.

     The Gram-negative bacilli isolated from the blood cultures Bordetella pertussis is the causative agent of whooping cough,

     (Bactec 9240, Peds Plus, and Plus Aerobic bottles; BD Diag- while Bordetella parapertussis and Bordetella bronchiseptica are

     nostics Inc., Sparks, MD) were small and coccoid. They tested also implicated in respiratory tract infections in humans. Bor- negative for catalase, oxidase, nitrate reduction, and urease detella avium is considered a strict avian pathogen but has activity as well as indole spot and oxidative-fermentative (OF) recently been isolated in the sputum of cystic brosis patients glucose media. The mean incubation time was 40 h (range, 30 h and others with respiratory disease (9, 19). Bordetella hinzii was to 47.3 h). Colonies grew well at 24 h when inoculated on 5% found to colonize the respiratory tract in poultry and also in humans with cystic brosis. It can occasionally cause infection sheep blood agar plates and incubated in 5% CO, whereas 2 in immunocompromised patients (5, 19, 23). Bordetella trema- only three strains showed very limited growth after 48 h on tum has been isolated from ear and wound infections and from MacConkey agar. While they were growing, they all produced a diffusible brown pigment which could have been mistaken for a diabetic patient with a leg ulcer (3, 22). Bordetella petrii has been documented in patients with cystic brosis (19), in a alpha-hemolysis on a sheep blood agar plate. We were unable patient with mandibular osteomyelitis, and in another with to identify the isolates through routine laboratory protocols and inoculation into API 20E and API 20NE strips (bio- mastoiditis (7, 20). It is noteworthy that, in this last patient, the Me?rieux Inc.). We nally used the Gram-negative card on a Vitek2 automated system misidentied the organism as Vitek2 automated system (bioMe?rieux Inc.), which reported Pseudomonas uorescens. A recently proposed species is Bor- Acinetobacter lwof;i with 99% probability (excellent identica- detella ansorpii, which was rst isolated in pus from an epider- mal cyst and was also found to cause bacteremia in an immu- nocompromised patient (6, 10). * Corresponding author. Mailing address: Division of Infectious B. holmesii was rst described in 1995 as a cause of septice- Diseases, Department of Pediatrics, CHU Sainte-Justine, University of mia in 15 patients, including at least three children with asple- Montreal, 3175 Coˆte-Sainte-Catherine, Montreal, Quebec H3T 1C5, nia, without any further clinical information (24). The rst Canada. Phone: (514) 345-4931, ext. 5566. Fax: (514) 345-4908. E-mail: detailed clinical case report was published later that year with the description of a 12-year-old male who had a history of Published ahead of print on 28 July 2010.


     VOL. 48, 2010 NOTES 3763 TABLE 1. Clinical characteristics and laboratory ndings for the 4 patients Result for patient: Parameter 1 2 3 4

    15 Age (yr) 13 17 13 Medical condition Sickle cell anemia Autoimmune Sickle cell anemia Sickle cell anemia hemolytic anemia Splenectomy Yes No Yes Yes Age at splenectomy (yr) 3 6 4 39.5 Temp (?C, maximum) 39.7 39.5 40 1 Duration of fever (days) 3 3 2 Treatment Ceftriaxone for 2 days Ceftriaxone for 7 days Ceftriaxone for 7 days Ceftriaxone for 5 days followed by ciprooxacin followed by ciprooxacin for 3 days for 5 days Blood hemoglobin level (g/dl) 9.7 12.1 9.5 11.7 3Platelet count/mm 321,000 677,000 261,000 396,000 3White blood cell count/mm 5,590 17,280 15,640 11,560 Neutrophils (%) 46 83 81 87 Normal Normal Chest X ray Normal Normal aOther test results Cardiac U/S, normal Tc/Ga scintigraphy, normal Tc/Ga scintigraphy, normal Length of hospital stay Not admitted 7 days 4 days 7 days

     a U/S, ultrasound; Tc/Ga, technetium-gallium. splenectomy for an idiopathic thrombocytopenic purpura. He strains possess a capsule or not remains unknown. Neverthe-

    less, overwhelming sepsis did not occur in our patients and are presented with fever but had an otherwise-normal physical

    not reported in the literature. examination. He quickly responded to i.v. ceftriaxone (11).

    The Vitek2 automated system failed to identify B. holmesii Since then, B. holmesii has been reported as a cause of bacter-

    because the microorganism is not included in its database. In emia, endocarditis, and pneumonia, mainly in immunocompro-

    addition, the system does not consider catalase activity or the mised and, more particularly, in asplenic patients (4, 8, 12, 13,

    presence of pigment. A. lwof;i was systematically erroneously 15, 18, 21). In the largest published series so far, describing 26

    patients with B. holmesii bacteremia, 85% had anatomical or reported with a high identication condence level.

    functional asplenia (18). The clinical course usually remained The above-described clinical cases and results of microbio- uneventful, and patients tended to recover without complica- logical analysis support the growing evidence for the role of B.

    tions. However, an immunocompetent adolescent with B. holmesii as a pathogen among asplenic patients and suggest holmesii bacteremia and lobar pneumonia developed empy- that it should always be considered, especially when the Vitek2 ema. He eventually evolved toward pulmonary brosis (17). In automated system reports A. lwof;i.

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